Ultrasound demonstration of anicteric dilatation of the biliary tree

Ultrasonography, CT, and ERCP in the Diagnosis of Choledochal Stones

A prospective study of jaundiced (n = 187) and nonjaundiced (n = 33) cholestatic patients was carried out to evaluate the sensitivity of ultrasonography (US), CT, and endoscopic retrograde cholangiopancreatography (ERCP) in the detection of choledochal stone disease. Altogether 83 patients had the final diagnosis of choledocholithiasis. In the jaundiced patients, the sensitivity of US, CT, and ERCP was 22.5%, 23.2%, and 80.6%, respectively. In cases of cholestasis without jaundice, the values were 20%, 37.5%, and 66.7%. In patients in whom all 3 imaging studies were done (n = 64), the differences between US and ERCP and between CT and ERCP were statistically significant (p < 0.0001). In most false-negative ERCP studies (10/15), the clinical course of the disease strongly suggested a passed choledochal stone. On the basis of this study, we recommend prompt ERCP to be performed if choledochal stone disease is suspected on clinical grounds.

Changing trends in the management of extrahepatic cholangiocarcinoma

A series of 107 patients with cholangiocarcinoma diagnosed between January 1980 and December 1991 is reported. Changing patterns of investigation and treatment in the periods 1980-1985 and 1986-1991 are analysed. There was a decrease in the use of percutaneous transhepatic cholangiography in the second period (86 versus 51 per cent of patients) but increased use of endoscopic retrograde cholangiography (19 versus 71 per cent) and computed tomography (8 versus 59 per cent). The overall resectability rate (17 per cent) was similar to those of other reported series but greater in the second period (8 versus 21 per cent). Palliation by endoscopic and percutaneous stenting was associated with a high incidence of recurrent cholangitis (55 per cent) and jaundice (35 per cent). During the second 6-year period, more effective palliation was achieved by segment III cholangiojejunostomy with a lower incidence of recurrent cholangitis (19 per cent) and jaundice (19 per cent). Overall prognosis for patients with this condition is grim and efforts must usually be aimed at providing the most appropriate palliation.

Biliary and pancreatic obstruction during gallstone migration

A prospective study on biliary and pancreatic obstruction during gallstone migration was performed in patients without acute pancreatitis. From January to October 1986, 125 patients with upper abdominal pain due to cholelithiasis were admitted to the hospital. Ultrasonography performed in all patients at admission demonstrated a distal bile duct measuring 7 mm or more in 39 patients, who were monitored for diameter changes of the biliary and pancreatic duct every 24 h and their stools screened for gallstones. Patients underwent surgery at least 8 days after admission. Gallstone migration was found preoperatively in 10 patients, of whom 6 had total serum bilirubin values lower than 2 mg/100 ml. Migration time was accurately determined by the sudden decrease in bile duct caliber. Simultaneous dilatation of biliary and pancreatic duct was found in 4 out of 10 patients with migrating gallstones and in 7 out of 23 patients without gallstone migration, though differences proved non-significant. Acute pancreatitis developed in 2 patients with lithiasis of the distal bile duct who ingested a fatty meal against medical advice. Gallstone migration, even of small stones, was preceded by a period of biliary obstruction. Pain and jaundice before migration were not as frequent as expected.

Value of sonography in obstructive jaundice. Limitations of bile duct caliber as an index of obstruction

The diagnostic value of sonography was assessed in 176 patients with jaundice who had a final diagnosis on the basis of surgery, autopsy, liver biopsy, endoscopic retrograde cholangiopancreatography, and serum tests positive for hepatitis A and B. Obstructive (n = 113) versus nonobstructive jaundice (n = 63) was diagnosed with a sensitivity of 91% and a specificity of 95%. Nine of the 10 false negatives had choledocholithiasis. Application of stricter criteria for common duct (CD) dilatation than the one used of CD greater than or equal to 8 mm to greater than or equal to 12 mm would have lowered the sensitivity from 91% to 84%. On the basis of these criteria the predicted level of obstruction would have shifted from distal to proximal in 36% of the patients. Choledocholithiasis was more often associated with decreasing bilirubin values than malignancy: 55% versus 9% (p less than 0.05). The present study indicates that intermittent obstruction, usually associated with choledocholithiasis, constitutes the main problem in detection of obstructive jaundice. Diameter criteria used for diagnosing dilatation of the CD may greatly influence sonographic accuracy.

Specific diagnosis of hepatocellular carcinoma by delayed hepatobiliary imaging

For assessment of the value of delayed hepatobiliary imaging with technetium 99m (99mTc)-(Sn)-N-pyridoxyl-5-methyltryptophan (99mTc-PMT) for specific diagnosis of hepatocellular carcinoma, 88 patients with various malignant and benign liver diseases (49 with hepatocellular carcinoma, 4 with cholangiocellular carcinoma, 10 with metastatic liver carcinoma, 2 with liver cysts, 2 with liver hemangioma, 1 with liver abscess, 2 with intrahepatic lithiasis, 12 with liver cirrhosis, and 6 with chronic hepatitis) were studied. In 20 (41%) of the 49 patients with hepatocellular carcinoma, greater uptake of 99mTc-PMT by the tumor than by the surrounding liver tissue was seen in delayed hepatobiliary images, whereas in eight patients (16%), equilibrated uptake was seen. No increased uptake of the radioisotope by hepatic lesions was seen in 21 patients with localized liver diseases other than hepatoma. Moreover, in 18 patients with diffuse liver diseases, no focal accumulation of the radioisotope was seen in delayed 99mTc-PMT images. In addition, of 28 patients with hepatocellular carcinoma in whom the serum alpha-fetoprotein level showed little or no increase, 12 showed increased uptake of 99mTc-PMT by the tumor. In assessing delayed 99mTc-PMT images, however, it was necessary to consider following complications: accumulation of tracer in obstructed and dilated biliary trees; retention of radioactivity in nonneoplastic liver tissues; difficulties in evaluating 99mTc-PMT uptake by small hepatic tumors; overlapping of radioactivity in the gut and gallbladder in delayed 99mTc-PMT images of tumors. This study indicates that delayed 99mTc-PMT images can be useful in the diagnosis of hepatocellular carcinoma.

Biliary tract dilatation without jaundice demonstrated by ultrasound

Upper abdominal ultrasonic examination demonstrated dilated bile ducts in eight patients with no history of jaundice and a normal serum bilirubin. All were proven subsequently to have extrahepatic biliary obstruction. It is important to recognise that ultrasound may be more sensitive than serum bilirubin in the diagnosis of extrahepatic biliary obstruction.

Caerulein in the treatment of biliary and renal colic

A randomized controlled study has been carried out in order to check the activity of caerulein in the treatment of biliary and renal colic. In 88% out of 107 patients caerulein, 1 ng/kg IV, relieved biliary colic and had no side effects. To elucidate the mechanism of action of the peptide, 22 cholecystectomized patients, showing a dilation of the common bile duct (CBD), were submitted to caerulein treatment under echo-control. Reduction of CBD caliber was noticed when the dilatation was due to functional obstruction, whereas an organic obstruction of the terminal tract of CBD was found in the non-responding patients. Caerulein appears to be an effective agent in relieving biliary colic through a relaxation of Oddi's sphincter, and may be used in ultrasound differential diagnostics of terminal bile duct obstruction. Caerulein, 75 ng/kg intramuscularly, relieved renal colic in 75% of the examined patients; it is suggested that the effect of caerulein in this syndrome is due to central analgesic action.

Imaging of the liver, biliary tract, and pancreas

The interaction between the various noninvasive and invasive imaging modalities used to evaluate the liver, biliary tract, and pancreas is demonstrated in this article. By understanding this interaction and correlating noninvasive studies, the clinician will avoid diagnostic redundancy and the need for invasive testing may be reduced.

Current concepts in diagnosis. Approach to the patient with cholestatic jaundice

On the basis of clinical evaluation, the physician should decide whether extrahepatic biliary obstruction is highly unlikely, possible, or very likely. If it is highly unlikely, no further workup for obstruction is indicated unless the clinical picture is altered on follow-up examination. Further evaluation of the biliary tree is warranted in other patients. Ultrasonography is currently the noninvasive imaging technique of first choice. Computed tomography is indicated if ultrasonography has yielded technically inadequate results or in special circumstances when it is anticipated that decisions regarding further diagnostic evaluation or treatment will be importantly influenced by the results. Negative findings obtained in a technically adequate examination may represent a logical stopping point in the workup of patients in whom obstruction is considered merely a possibility to be excluded, but they should not dissuade the clinician from further diagnostic evaluation if obstruction is considered very likely. Indeed, in selected circumstances, such as cases in which choledocholithiasis is suspected after cholecystectomy, direct cholangiography is appropriate as an initial test. If evidence of obstruction is obtained by noninvasive imaging, direct cholangiography will be required in many patients before treatment, and the choice between percutaneous or retrograde cholangiography should be made on an individual basis. The challenge to the clinician is to minimize the risk, expense, and time involved in obtaining sufficient information for a definitive diagnosis and treatment.